Search

Well-developed collaterals are assumed as a marker of viability and ischemia in chronic total occlusions (CTO). We aim to correlate viability and ischemia with collateral presence and extent in CTO patients by cardiac magnetic resonance (CMR).Multicentre study of 150 CTO patients undergoing stress-CMR, including adenosine if normal systolic function, high-dose-dobutamine for patients with akinetic/2 hypokinetic segments and EF ≥35%, otherwise low-dose-dobutamine (LDD); all patients underwent late gadolinium enhancement (LGE) imaging. Viability was defined as mean LGE transmurality ≤50% for adenosine, as functional improvement for dobutamine-stress-test, ischemia as ≥1.5 segments with perfusion defects outside the scar zone.Rentrop 3/CC 2 defined well-developed (WD, n = 74) vs poorly-developed collaterals (PD, n = 76). Viability was equally prevalent in WD vs PD: normo-functional myocardium with ≤50% LGE in 52% vs 58% segments, p = 0.76, functional improvement by LDD in 48% vs 52%, p = 0.12. Segments with none, 1-25%,26-50%,51-75% LGE showed viability by LDD in 90%,84%,81%,61% of cases, whilst in 12% if 76-100% LGE (p 0.01). There was no difference in WD vs PD for ischemia presence (74% vs 75%, p = 0.99) and extent (2.7 vs 2.8 segments, p = 0.77).In a large cohort of CTO patients, presence and extent of collaterals did not predict viability and ischemia by stress-CMR. Scar extent up to 75% LGE was still associated with viability, whereas ischemia was undetectable in 25% of patients, suggesting that the assessment of CTO patients with CMR would lead to a more comprehensive evaluation of viability and ischemia to guide revascularization.

A 21–year old male who underwent surgical closure of an isolated inferior type sinus venosus atrial septal defect (SV–ASD) at 6 years of age was admitted to our institute for acute superior limb hypotonia and dysarthria, with brain computed tomography scan positive for an ischaemic event. The contrast transcranial Doppler (CTD) was positive for right–to–left shunt (RLS). The transesophageal echocardiogram (TOE) revealed a small ASD (3.8 mm) near the inferior vena cava (IVC) with a small baseline left–to–right shunt and severe RLS after Valsalva’s Manovre (>20 bubbles) (fig.A–B). No clear intra–cardiac source of embolization was detected on workup. After a multidisciplinary discussion, percutaneous closure of residual ASD was planned. The main challenge was represented by inadequate inferior–posterior rim towards the IVC ( Conclusions Residual ASD is a rare late complication after surgical closure of the ASD(1). We describe the case of a successful transcatheter closure of a small ASD in the presence of a deficient posterior–inferior rim which, in general, is considered an unfeasible anatomy for percutaneous procedure (2). The appropriate choice of treatment for a residual ASD should be carefully considered on a case–by–case basis. Reference 1) S. Ogura;Y.Takaya1; T. Akagi; K. Nakagawa; H. Ito.Percutaneous closure of residual atrial septal defect after surgical closure. Cardiovascular Intervention and Therapeutics (2021) 36:256–259 2) M. Chessa; G. Butera; A. Giamberti; R. M. Bini; M.Carminati. Transcatheter Closure of Residual Atrial Septal Defects After Surgical Closure. Journal of Interventional Cardiology vol.15, No. 3,2002

BACKGROUND Patients with diabetes mellitus (DM) represents a challenging subset of population as they experience worse outcomes after percutaneous coronary intervention than patients without diabetes. We evaluated the 2-year efficacy and safety profile of the Abluminus DES+ in patients with diabetes within the population enrolled in the large multicenter en-ABL e-registry. METHODS Multicenter, prospective, all-comers registry performed in 31 centers in India. We analyze patients according to the diagnosis of DM and insulin dependency (ID or Non-ID): non-DM (1641 patients), NIDDM (721 patients), IDDM (138 patients). The primary endpoint was a composite of device-oriented major adverse cardiac events (MACE): cardiac death, target vessel-related myocardial infarction (MI), and ischemia-driven target lesion revascularization (TLR)/ target vessel revascularization (TVR) at 2-year. Stent thrombosis (ST) at any time point was also recorded. RESULTS The MACE rate at 2-year follow-up was 3.0% in the overall population with DM patients showing a higher rate of primary endpoint compared to non-DM (4.4% vs. 2.4%, P=0.025). Rate of cardiac death was actually low and consistent between the 2 groups (1.7% vs. 0.9%, P=0.100). At 2-year follow-up, the rate of ST was 0.9% in DM patients versus 0.5% in non-DM, P=0.213. CONCLUSIONS At 2-year follow-up, the Abluminus DES+ technology that merges the features of a sirolimus coated balloon with those of a bioresorbable polymer drug eluting stent appears to be safe and effective. This safety/efficacy profile was consistent in patients with or without DM.

Background MitraClip procedure is a treatment option in patients with symptomatic mitral regurgitation (MR) and prohibitive surgical risk. Echocardiographic evaluation of mitral valve (MV) is of paramount importance for the correct identification of patient eligibility and procedural success. Our aim is to assess the acute effect of device implantation on mitral annular geometric parameters still little explored with the use of three-dimensional (3D) transoesophageal echocardiography (TEE) and to investigate its relationship with residual MR at discharge. Methods 67 consecutive patients (mean age78.7±7.2 yrs, 41 males) undergoing percutaneous MV repair with MitraClip in our Centre were enrolled. Patients eligibility was evaluated according to the EVEREST criteria and current guidelines. Four groups were identified on the base of MR aetiology: 22 were degenerative (DMR), 19 ischemic functional (IFMR), 19 non-ischemic functional (NIFMR) and 7 atrial functional (AFMR). 3D TEE was performed before and immediately after clip deployment with MV anatomical quantification by PHILIPS® QLAB MVQ and GE® 4D-AUTO-MVQ software. Results Severe MR (4+) was found in 17 pts, and moderate-severe MR (3+) in 50 pts. Thirteen cases were unsuccessful because of unchanged or residual MR>2+. Immediately after device positioning, almost all the evaluated parameters showed a significant modification within each group with a reduction of anterior-posterior (AP-D) and bi-commissural (CC-D) MV diameters, MV annulus area and perimeter and an increase in tenting volume, tenting height and posterior mitral leaflet angle (PML α). Anterior mitral leaflet angle (AML α), sphericity index and aorto-mitral angle remained unchanged. We observed no significant difference in the sub-analysis between degenerative and all functional MR groups, although a different trend of parameters variation could be evidenced. Post-procedural tenting height with cut off of 5.5 mm was a predictor of procedural success (see fig.), while at univariate analysis basal AP-D in DMR group and sphericity index, PMLα and annulus height at baseline in the FMR group were all significantly correlated to the entity of MR reduction at discharge. Conclusions Percutaneous edge-to-edge repair with MitraClip acutely changes the MV annular geometry in degenerative and both ventricular and atrial functional MR, with a different trend within each group. Post-procedural tenting height correlates with significant MR reduction at discharge, a promising marker that could be used in clinical practice for identification of MitraClip procedure success. Funding Acknowledgement Type of funding source: None

Background the TAPSE/SPAP ratio has gained a role as an easy-to-use surrogate of right ventricle-to-pulmonary circulation (RV-PC) coupling, showing a strong prognostic significance in heart failure (HF) patients. The hemodynamic determinants of TAPSE/SPAP ratio, as assessed by invasive approach, have not been fully clarified. Aim To identify the right heart hemodynamic variables correlated with TAPSE/SPAP in a HF with reduced EF (HFrEF) cohort, both at rest and during exercise. Methods 30 HFrEF patients (age 68 ± 10 years LV EF 28 ± 7) underwent to rest and exercise echocardiography and performed right heart catheterization within 24 hours. Bivariate correlations between TAPSE/SPAP ratio (at rest and during exercise), right heart hemodynamic variables, RV systolic function and NTproBNP have been explored. Results TAPSE/SPAP ratio at rest showed a moderate correlation with pulmonary artery wedge pressure (PAWP: r= 0.441; p= 0.039), pulmonary artery pressures (PAP systolic: r = 0.481; p= 0.026; PAP diastolic: r= 0.434; p= 0.043; mPAP: r= 0.476; p= 0.025), pulmonary vascular resistance and compliance (r= 0.475; p= 0.041). A stronger correlation was identified with right atrial (RAP systolic: r= 0.586; p= 0.017; RAP diastolic: r= 0.681; p= 0.006) and right ventricular pressures- in particular diastolic ones (RVP systolic: r= 0.584; p= 0.004; RAP diastolic: r= 0.652; p= 0.002). No significant correlation with NTproBNP and RV 3D EF emerged. Exercise TAPSE/SPAP ratio significantly correlated with right atrium (RAP systolic: r= 0.564; p= 0.036) and right ventricle systolic pressures only (RVP systolic: r= 0.789; p< 0.001). Conclusions TAPSE/SPAP ratio at rest showed a stronger correlation with invasively derived diastolic right heart pressure rather than pulmonary vascular bed pressures. A similar correlation was also observed for exercise TAPSE/SPAP ratio. This tight correlation with RV, rather than with vascular pressures, supports the significance of this ratio as a marker of RV adaptation to vascular overload.

Background The TAPSE/SPAP ratio has gained a role as an easy-to-use surrogate of right ventricle-to-pulmonary circulation (RV-PC) coupling, showing a strong prognostic significance in heart failure (HF) patients. The hemodynamic determinants of TAPSE/SPAP ratio, as assessed by invasive approach, have not been fully elucidated. Aim To identify the right heart hemodynamic variables correlated with TAPSE/SPAP in a HF with reduced EF (HFrEF) cohort, at rest and during exercise. Methods 24 HFrEF patients (age 67±11 years LV EF 27±7) underwent to rest and exercise echocardiography and performed right heart catheterization within 24 hours. Bivariate correlations between TAPSE/SPAP ratio (at rest and exercise), right heart hemodynamic variables, RV systolic function and NTproBNP have been explored. Results TAPSE/SPAP ratio at rest showed a moderate correlation with pulmonary artery wedge pressure (PAWP: r=0.432; p=0.039), pulmonary artery pressures (PAP systolic: r=0.474; p=0.026; PAP diastolic: r=0.434; p=0.043; mPAP: r=0.476; p=0.025), pulmonary vascular resistance and compliance (r=0.475; p=0.041), while a stronger correlation was identified with right atrial (RAP systolic: r=0.571; p=0.017; RAP diastolic: r=0.675; p=0.006) and right ventricular pressures- in particular diastolic ones (RVP systolic: r=0.584; p=0.004; RAP diastolic: r=0.646; p=0.002). No significant correlation was found with NTproBNP and RV 3D EF. Exercise TAPSE/SPAP ratio significantly correlated with right atrium (RAP systolic: r=0.564; p=0.036) and right ventricle systolic pressures only (RVP systolic: r=0.765; p TAPSE/PAPS correlation graphics Conclusions TAPSE/SPAP ratio at rest showed a stronger correlation with invasively derived diastolic right heart pressure rather than pulmonary vascular bed pressures. A similar correlation was also observed for exercise TAPSE/SPAP ratio. This tight correlation with RV, rather than vascular pressures, supports the significance of the ratio as a marker of RV adaptation to vascular overload.

SummaryThe functional contribution of somatostatin-expressing interneurons (SST-INs) to the synaptic organization of the striatum is poorly understood. Using electrophysiological recordings, optogenetic stimulation, and single-cell PCR analysis, we investigated functional patterns of synaptic connectivity in striatal SST-INs expressing channelrhodopsin-2. Photostimulation of these cells induced both glutamatergic excitatory postsynaptic currents (EPSCs) and GABAergic inhibitory postsynaptic currents (IPSCs) in striatal spiny projection neurons (SPNs) and fast-spiking interneurons (FSIs). The two synaptic components showed equally fast onset latencies, suggesting a mechanism of co-transmission. Accordingly, single-cell PCR analysis revealed that individual striatal SST-INs expressed mRNAs for both glutamate and GABA vesicular transporters (VGLUT1 and VGAT, respectively). During relatively prolonged optical stimuli (0.5-1s), IPSC arrays consistently outlasted EPSCs. As a result, photostimulation of SST-INs caused a transient burst of action potentials followed by a prolonged inhibition in postsynaptic cells.These data suggest that striatal SST-INs are specialized to locally project synapses exerting a composite excitatory and inhibitory effect through GABA/glutamate co-transmission onto different postsynaptic targets.

Prosthesis positioning in transcatheter aortic valve implantation procedures represents a crucial aspect for procedure success as demonstrated by many recent studies on this topic. Possible complications, device performance, and, consequently, also long-term durability are highly affected by the adopted prosthesis placement strategy. In the present work, we develop a computational finite element model able to predict device-specific and patient-specific replacement procedure outcomes, which may help medical operators to plan and choose the optimal implantation strategy. We focus in particular on the effects of prosthesis implantation depth and release angle. We start from a real clinical case undergoing Corevalve self-expanding device implantation. Our study confirms the crucial role of positioning in determining valve anchoring, replacement failure due to intra or para-valvular regurgitation, and post-operative device deformation.

Increasing evidence suggests that percutaneous coronary intervention with newer generation drug-eluting stents may be an acceptable alternative, or even preferred in selected cases to the surgical approach, in patients with left main disease. This review will discuss the anatomic factors, the clinical variables, and the procedural strategies to consider, including physiology assessment and imaging guidance, in order to optimize outcomes.

From the first quarter of 2014, a new generation of transcatheter valves (Fig. 8.1) has CE mark approval for clinical use in Europe and under scrutiny for FDA approval in the United States. These new valves aim to overcome or to reduce the major limitations of first-generation valves (Edwards XT and CoreValve) as paravalvular leak, vascular complications, cardiac rhythm disturbances, and stroke. We describe below the technical features and the first clinical results of the new transfemoral devices.

Catheter-based treatment of aortic regurgitation (AR) often proves challenging especially due to associated anatomical difficulties. Here, we present a case of CoreValve implantation with a novel use of the valve-in-valve technique to effectively treat severe AR in a patient with repeated cardiac surgery and aneurismatic prosthetic ascending aorta. © 2013 Wiley Periodicals, Inc.

Aim: Elevation of Troponin after scheduled percutaneous coronary intervention (PCI) is a recognized consequence. We sought to evaluate the prognostic significance and impact of the newly published definition of PCI-related myocardial infarction (MI) according to which any troponin elevation >3 times the upper reference limit identify a peri-procedural MI. Methods: Search of BioMedCentral, CENTRAL, mRCT and PubMed (updated May 2008). Outcomes of interest were: MACE [the composite of all cause death, MI, repeat target vessel PCI (re-PCI) and coronary artery bypass grafting (CABG)]; single end points were also assessed. Results: Fifteen studies have been included totalling 7578 patients. Troponin elevation occurred in 28.7% of the procedures. The incidence of PCI-related MI according to the new definition was 14.5%. During the hospitalization, any level of raised troponin was associated with an increased risk of MACE [OR 11.29 (3.00–42.48), Number needed to harm (NNH) 5], death [OR 7.16 (1.95–26.27), NNH = 100], MI [OR 30.85 (6.05–157.38), NNH = 4] and re-PCI [OR 4.13 (1.23–13.88), NNH = 50]. Patients with PCI-related MI had an increased risk of death [OR 17.25 (2.71–109.96), NNH = 100] and re-PCI [OR 10.86 (3.2–36.94), NNH = 25]. At follow up of 18 months any troponin elevation was associated with an increased risk of MACE [OR 1.48 (1.12–1.96), NNH = 20], death [OR 2.19 (1.59–3.00), NNH = 50], MI [OR 3.29 (2.71–6.31), NNH = 33] and re-PCI [OR 1.47 (1.06–2.03), NNH = 25]. In patients with PCI-related MI the risk of MACE was further increased: OR 2.25 (1.26–4.00), NNH = 3. An increase of the troponin level below the cut-off was not associated with MACE. Conclusion: A diagnosis of MI according to the new guidelines applies to 15% of patients undergoing PCI and these patients are at high risk of further adverse events both during the hospital stay and at 18 months.

Background: Vit-K antagonists are the therapy of choice to prevent thromboembolic events due to atrial fibrillation since many years. New oral anticoagulants (NOA) showed encouraging results vs. warfarin but there are no data directly comparing different NOA. We performed an adjusted indirect meta-analysis. Methods: Randomized controlled trials (RCTs) were searched. Efficacy end points were the cumulative rate of thomboembolic stroke (TES) and systemic embolism (SE). Main safety end point was the rate of hemorrhagic stroke (HS). Results: Three RCTs (50578 patients) were included. Overall, NOA were comparable to warfarin according to the cumulative risk of TES and SE, as well as for TES alone. NOA were associated with a reduced rate of SE [OR 0.64 (0.44, 0.94], P = 0.02]. Compared to warfarin, NOA were associated with a significantly reduced risk of HS [OR 0.43 (0.34, 0.55), P 0.05). Rivaroxaban showed superiority in the prevention of SE. Dabigatran 150 mg/twice daily was associated with the largest reduction in the risk of HS vs. warfarin and vs. other NOA. Overall mortality was quite comparable across NOA. Conclusions: Overall superiority of NOA over warfarin is largely influenced by the reduction of HS. Dabigatran 150 mg/twice daily seems to have the best risk/benefit profile.

Thienopyridines are a class of drug targeting the platelet adenosine diphosphate 2 receptor. They have been shown to significantly reduce platelet activity exerting an important role in those clinical settings in which such an effect is beneficial. Ticlopidine was first to be introduced several years ago but it was quickly replaced by clopidogrel as it had a better risk/benefit profile. Recently, prasugrel has been developed and tested in several ex vivo studies and clinical trials showing able to provide a more powerful antiplatelet effect at the expense of a higher risk of bleeding complications. Great debate rose around its recent approval in the US as well as in Europe. This review aims at exploring the development and available clinical data of this third-generation thienopyridine while discussing its practical implementation in routine practice.

Thienopyridines are a class of drug targeting the platelet adenosine diphosphate (ADP) 2 receptor. They significantly reduce platelet activity and are therefore clinically beneficial in settings where platelet activation is a key pathophysiological feature, particularly myocardial infarction. Ticlopidine, the first of the class introduced to clinical practice, was soon challenged and almost completely replaced by clopidogrel for its better tolerability. More recently, prasugrel and ticagrelor have been shown to provide a more powerful antiplatelet action compared to clopidogrel but at a cost of higher risk of bleeding complications. Cangrelor, a molecule very similar to ticagrelor, is currently being evaluated against clopidogrel. Considering the key balance of ischemic protection and bleeding risk, this paper discusses the background to the development of prasugrel, ticagrelor, and cangrelor and aims to characterise their risk-benefit profile and possible implementation in daily practice.

To the Editor: We read with interest the article by Kramer et al1 assessing the possible relationship between thrombus age and outcome in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention and undergoing thrombus aspiration. The authors concluded that thrombus age is an independent predictor of an adverse outcome. However, in our opinion, several issues require further insights. First, different aspiration devices have been …

About 50% of patients with cryptogenic stroke have a patent foramen ovale (PFO). The recurrence rate of paradoxical embolism is higher if a PFO is detected.Thirty-five patients with PFO andor = 1 thromboembolic event due to paradoxical embolism were included in the study (23 males, 12 females, mean age 47.8 +/- 14 years, mean weight 75 +/- 15 kg). Twenty-three patients had a transient ischemic attack whereas 12 experienced an ischemic stroke. Twenty-nine patients had one thromboembolic event, 4 patients had two thromboembolic events, and 2 patients had three thromboembolic events. The implantation procedure was performed, as previously reported, under general anesthesia, fluoroscopic guidance and during transesophageal echocardiography.The implantation procedure was successful in all patients. There were no complications related to the procedure. Four different devices were implanted (Amplatzer 3 patients; Cardioseal 12 patients; Starflex 12 patients, PFO Star 8 patients). The procedure time and fluoroscopic time were 50 +/- 21.8 and 12.2 +/- 8.3 min respectively. At transesophageal echocardiography performed after the procedure, 11 patients had a trivial shunt. None of the patients had a residual shunt at 1 month of follow-up. The mean follow-up was 12.3 +/- 8 months (median 11.0 months, range 3-37 months). In no patient did recurrence of a thromboembolic event occur during follow-up.Percutaneous PFO closure is a feasible and safe technique for the prevention of recurrent paradoxical embolism.

This report describes a patient with variant angina who had a positive ergonovine test successfully antagonized by intracoronary nitroglycerin and who developed a late recurrence of coronary spasm followed by reversible electromechanical dissociation.

Rapid technological developments have made new materials available for percutaneous coronary intervention procedures. The coronary stent in particular has undergone progressive structural improvements leading to the recent availability of a third generation of stents, namely, coated stents. The rapid evolution of the stent has often made its evaluation problematical, since trials are frequently confined to small groups of patients in single centers. The purpose of this registry was to verify the safety and efficacy of the BiodivYsio stent (a stent coated with phosphorylcholine polymer) in a broad population of patients who reflect the daily reality of coronary intervention in a cardiac catheterization laboratory.The registry was designed to collect the principal angiographic and clinical data of a consecutive series of Oreal worldO patients. Patients were treated with a BiodivYsio stent (Biocompatibles, Galway, United Kingdom) in 12 centers (11 Italian and 1 Swiss) between January 1998 and January 1999. Procedural, in-hospital, 30-day and six-month follow-up data were collected. The monitoring, data entry and statistical analyses were carried out by an independent center. During the study, 218 patients were enrolled; 165 (76%) male and 53 (24%) female, with an average age of 61.6 +/- 9.4 years (range, 36Eth 84 years). A total of 258 stents were implanted in 233 lesions (1.1 stents per lesion), of which 233 (90%) were the BiodivYsio PC coated stent, the remaining 25 implants were of other stent types. The percutaneous transluminal coronary angioplasty and stenting procedure were carried out in 109 (50%) patients with unstable angina, 65 (30%) with stable angina, 29 (13%) with acute myocardial infarction, and 15 (7%) patients with silent ischemia. Procedural success was achieved in 217/218 (99.5%) patients. Optimal results were achieved in 212 (97.7%) patients. In 34 (15.6%) cases, patients were treated with periprocedural abciximab. During the hospitalization period, one (0.4%) death occurred on day 7 due to subacute occlusion of the stent, and 3 (1.4%) myocardial infarctions were reported. At 30-day follow-up, 211 (97.2%) patients were asymptomatic, as were 189 (87%) patients at clinical follow-up at 6 months.This study evaluated the safety and efficacy of a third-generation stent. The results demonstrate a high procedural success rate and a low incidence of major adverse cardiac events at short- and medium-term follow-up. It appears that the BiodivYsio stent should be considered safe in clinical and/or anatomical situations with a high risk of complications, confirming the hypothesis that PC may have non-thrombogenic properties. To corroborate these results, an appropriately designed study would be required to measure the stentOs efficacy in the most suitable clinical context, i.e., clinical situations that are at the highest risk of ischemic relapse.

Although many previous reports showed a worse outcome after rescue compared to primary coronary angioplasty, a direct comparison of these two strategies in the era of stenting is lacking.Fifty patients treated with rescue stenting were retrospectively compared to 61 patients treated with primary stenting during acute myocardial infarction over a 4-year period in our Laboratory.Baseline demographic and angiographic parameters were not significantly different in the two groups. Despite a significantly longer time-to-reperfusion in rescue stenting (4.7 +/- 2.7 vs 2.8 +/- 2.1 hours, p0.0001), procedural success rate (98 vs 97%), in-hospital mortality (6 vs 11%) and target vessel revascularization at 6 months (8 vs 10%) were similar in rescue compared to primary stenting.These data suggest that stenting may help improve results of rescue angioplasty, and support the concept that aggressive treatment after failed thrombolysis can be pursued with satisfactory results.

Two patients are described with anterior acute myocardial infarction who had a successful recanalization of a totally occluded left anterior descending coronary artery by means of primary angioplasty and stenting. Reinfarction occurred more than 1 month after implantation. At angiography, a totally occluded left anterior descending coronary artery at the site of stenting was observed and was effectively reopened with angioplasty and stenting in both cases. This report aims to emphasize that acute myocardial infarction still represents a major risk factor for subacute stent thrombosis and that this potentially catastrophic event may occur late after implantation. Potential implications for revascularization strategies and medical treatment are discussed.

Although recent data show that coronary stenting reduces procedural complications and late restenosis, major concern has been expressed about the greater hospital cost associated with the use of this device as compared to conventional coronary angioplasty. Since length of hospital stay after surgical procedures is a major determinant of resource use, the identification of variables associated with an excessively long hospital stay after intracoronary stent placement may have important practical consequences. The purpose of this study was to assess factors responsible for the occurrence of in-hospital complications and prolonged hospital stay after coronary stenting in 939 consecutive patients enrolled in the Registro Impianto Stent Endocoronarico (RISE Study Group). Consecutive patients undergoing coronary stent implantation at 16 medical centers in Italy were prospectively enrolled in the Registry. Clinical data, qualitative and quantitative angiographic findings were obtained from data collected in case report forms at each investigator site. Major ischemic complications were considered death, Q-wave myocardial infarction, emergency bypass surgery and emergency repeat angioplasty. The study group consisted of 939 patients (781 men, 158 women with a mean age of 59 years) in whom 1392 stents were implanted in 1006 lesions and expanded at a maximal inflation pressure of 14.7 +/- 3 atmospheres. The great majority of patients (92%) received only antiplatelet drugs after coronary stenting. During hospitalization, there were 45 major ischemic complications in 39 patients (4.2%): 13 events were related to acute or subacute thrombosis (1.4%). On multivariate logistic regression analysis, the following factors were predictive of in-hospital complications: increasing age (OR 2.19, 95% CI 1.18-4.07), unplanned stenting (OR 3.46, 95% CI 1.65-7.23) and maximal inflation pressure (OR 0.83, 95% CI 0.75-0.93). Mean hospital stay after stent implantation was 4.1 +/- 4.4 days and was related, by multivariate regression analysis, to female sex (p = 0.0001), prior bypass surgery (p = 0.03), non-elective stenting (p = 0.0001), use of anticoagulation (p = 0.0001) and development of major ischemic complications (p = 0.0001). This Registry shows that in an unselected population of patients undergoing coronary stenting, major ischemic complications occur at a relatively low rate (4.2%) and thrombotic events can be kept at 1.4%, despite the omission of anticoagulation in the great majority of patients. Length of hospital stay was affected by the occurrence of major ischemic complications, unplanned stenting, use of anticoagulation, female sex and prior bypass surgery. Accumulating experience, further reduction in complications and complete omission of anticoagulation may decrease length of hospital stay, thus reducing the use of resources after coronary stenting.

A case of coronary occlusion occurred seven days after successful percutaneous transluminal coronary angioplasty. The acute complication occurred shortly after a negative exercise stress test and was resolved with intracoronary urokinase.

Right ventricular (RV) function and morphometric quantitation of interstitial fibrosis in idiopathic dilated cardiomyopathy (IDC) have not been the subject of specifically designed clinical observations. In particular, their role in routine assessment and prognostic evaluation of patients (pts) with IDC remains to be settled.Eighty-one consecutive IDC patients (63 M, 18 F; mean age 52 +/- 11 yrs) with left ventricular (LV) systolic dysfunction (angiographic ejection fraction - EF -55%), normal coronary arteries and no histologic evidence of myocarditis were studied. Cardiac catheterization and endomyocardial biopsy (EMB) were routinely performed in all cases. RV volumes and EF were obtained by angiography according to Ferlinz' method and interstitial fibrosis was quantitated by computer-assisted morphometric analysis. These data were analyzed in order to study correlations with hemodynamic parameters and to assess their prognostic value in a long-term follow-up.In the study population, right ventricular EF was significantly lower than in normal controls (35 +/- 11% vs 53 +/- 6%, p0.0001) and showed a significant positive correlation with LV EF (r = 0.54; p0.0001), and a weak but significant negative correlation with fibrosis (r = -0.29; p = 0.03). RV volumes, but not EF, were significantly related to mean pulmonary pressure. At multivariate analysis, RV end-diastolic volume (EDV) and EF were the two independent predictors of severe heart failure (NYHA class III-IV). After a mean follow-up of 64 +/- 36 months, 20 pts died and 9 had heart transplantation, for a 63% transplant-free survival rate (TFS). Multivariate analysis identified three independent predictors of TFS: LV stroke work index (p0.0001), RV stroke work index (p = 0.02) and RV EDV (p = 0.03). Fibrosis was predictive of survival only in the subgroup with LV EF20%.Assessment of RV function provides useful information in the evaluation of hemodynamic profile and prognosis of pts with IDC. Quantitation of interstitial fibrosis by morphometry provides little additional data.

Cardiac troponin I, a specific and sensitive marker of myocardial damage, was detected in the blood of 6 of 26 patients studied in our Heart Failure Clinic. In these patients functional class, ventricular function, and prognosis were significantly worse than in those without detectable troponin I. This study suggests that troponin I may represent the biochemical marker of myocardial damage occurring in severe heart failure.

The development of methods for the detection of circulating CK-MB mass, cardiac troponin T (cTn-T) and troponin I (cTn-I) has increased the diagnostic potential in the identification of myocardial damage. Coronary angioplasty (PTCA) represents a widely accepted revascularization procedure and a clinical model of induced ischemia. Using these new biochemical markers, we evaluated the incidence and the clinico-procedural correlates of minor myocardial damage (MMD) in a series of patients treated with PTCA in our Department. In 57 consecutive patients (75% males; mean age 58 years; range 35-80) undergoing elective PTCA from March 1 to June 30, 1995, serum levels of CK-MB mass, cTn-T and cTn-I were measured at baseline and at 6, 12 and 24 hours after the procedure. Seventy-eight coronary stenoses were dilated (mean 1.4 lesion/patient), 17 of these were in infarct-related vessels; 8 were total occlusions and 2 were located in saphenous vein grafts. Twenty-two procedures were completed by coronary stenting (17 elective). cTn-T and cTn-I were considered abnormal when serum levels were0.2 ng/ml and0.6 ng/ml, respectively. CK-MB mass was also determined in all patients (abnormal5 ng/ml). No patients had clinical or electrocardiographic evidence of myocardial infarction after the procedure. Overall, 16 patients (28%) developed biochemical evidence of post-procedural MMD (defined as the presence of at least one abnormal sample of any among the three markers tested). Four (7%) had abnormal CK-MB mass (at least one sample), 9 (16%) abnormal cTn-T, and 15 (26%) abnormal cTn-I. When CK-MB mass was elevated, both cardiac troponins were also elevated. In patients positive for MMD and abnormal CK-MB mass, peak cTn-I was significantly higher than in patients with normal CK-MB (3.02 +/- 1.07 vs 1.02 +/- 0.11 ng/ml; p = 0.009). The difference was not evident when comparing the same groups of patients for cTn-T (0.26 +/- 0.04 vs 0.18 +/- 0.10 ng/ml; p = 0.16). Also, peak cTn-I but not peak cTn-T had a positive correlation with peak CK-MB mass (r = 0.89; p0.0001 and r = 0.23; p = 0.40). The elevation of either marker of MMD was not related to clinical, angiographic or procedural variables. A possible interpretation for MMD was found in 2/3 of cases: bail-out (2); late occlusion (1); minor side branch occlusion (3); distal embolization from saphenous vein grafts (2) or total occlusions (2). In our series, MMD after PTCA occurs in 28% of cases and is unrelated to clinical, angiographic and procedural variables. Both cTn-T and cTn-I increase the sensitivity of CK-MB mass in the detection of MMD after PTCA, cTn-I being the most sensitive marker. In about 1/3 of cases, the presence of MMD remains unexplained. The prognostic implications of MMD are as yet undefined.

Objectives: To report clinical outcomes in patients treated with drug-eluting balloon (DEB) for in-stent restenosis (ISR) involving a bifurcation lesion. Background: Previous studies have examined the role of DEB in ISR but data on its use specifically at bifurcation sites is lacking. Methods: We retrospectively evaluated all patients who underwent percutaneous coronary intervention with DEB for bifurcation ISR between February 2007 and November 2012. Results: A total of 83 bifurcation restenoses (65 main-branch lesions and 73 side-branch lesions) in 77 patients in which DEB was used either in the main-branch and/or side-branch were analyzed. Thirty one (40.3%) patients were diabetic. The majority of restenosis was seen with first-generation drug-eluting stents (49.4%). Twenty-three (27.7%) bifurcations had already received a stent for a previous ISR (stent-in-stent). During the median follow-up period of 390 days, 18 (23.4%) major cardiac adverse events occurred: 2 (2.6%) cardiac deaths, 2 (2.6%) periprocedural myocardial infarctions, and 15 (19.5%) TVR, of which 10 (13.0%) were target lesion revascularizations (TLR) (n=11/83, 13.3% per bifurcation). There were no cases of follow-up MI or stent thrombosis (definite and probable). TLR was more frequently recorded in the stent-in-stent group (n=10/23, 43.5%), as compared to the first restenosis group (n=1/60, 1.7%). Conclusions: Our results demonstrate that DEB for bifurcation restenosis may be an acceptable treatment option, especially in cases where repeat stenting has not already been used for the treatment of a previous restenosis.

Sixteen patients (15 males, 1 female; mean age 63 years, range 45-78) with severe heart failure (NYHA class III = 5; class IV = 11) secondary to ischemic heart disease (8), dilated cardiomyopathy (5) and valvular heart disease (3), were evaluated for eligibility to intermittent Dobutamine (D) treatment. As a part of this evaluation, they were submitted to an acute dose-ranging test with D, up to 10 micrograms/Kg/min under hemodynamic and electrocardiographic monitoring. By inclusion criteria, all patients had:-cardiac index (CI)2.2 L/min/m2;-pulmonary wedge pressure (WP)18 mmHg;-left ventricular ejection fraction (EF)30%. At each step of the procedure, hemodynamic measurements and blood sampling for atrial natriuretic peptide (ANP) concentration were performed.Peak effect, defined as the dose corresponding to the maximum increase in CI, was reached at a mean of 7.8 +/- 0.5 micrograms/Kg/min. CI increased from 1.7 +/- 0.3 to 2.53 +/- 0.7 L/min/m2 (p0.001) and ANP decreased from 234 +/- 112 to 173 +/- 118 pg/ml (p0.001). Correspondingly, heart rate, stroke volume index and stroke work index increased, while right atrial pressure (RAP), mean pulmonary artery pressure (PAP), WP, systemic and pulmonary vascular resistance all significantly decreased. Mean arterial pressure was not affected. Changes in ANP concentration correlate significantly with changes in WP and in PAP (r = 0.65, p0.05 and r = 0.89, p0.001, respectively), but not with changes in RAP (r = 0.26, p = 0.34). Patients showing an increase40% in CI or a CIor = 2.5 L/min/m2 at peak effect (responders) had significantly lower baseline PAP with respect to non-responders. Besides PAP, baseline ANP levels, end-systolic pressure/volume ratio and ejection fraction were also independent predictors of response. The test did not induce complex arrhythmias and was well tolerated in all patients.Patients with severe heart failure retain the ability to respond to acute administration of D. with a significant improvement in their hemodynamic profile. Response to D. administration is predicted by lower baseline pulmonary pressure and ANP levels and a lesser degree of left ventricular dysfunction. Despite high baseline ANP concentration, a significant decrease is obtained which parallels the decrease in pulmonary artery and pulmonary wedge pressure, but is not related to changes in right atrial pressure. These findings suggest that changes in left ventricular performance induced by D. are the major determinants of the decrease in ANP concentration in this clinical setting.

To evaluate the prevalence of carotid lesions and silent coronary artery disease in asymptomatic patients, we studied 31 subjects with one or more risk factors for atherosclerosis. All patients have been studied by means of non invasive cardiologic evaluations and carotid echo color Doppler. The prevalence of carotid and or coronary artery disease was 80%. The prevalence of silent coronary artery disease was 19% and carotid artery disease 61%. Patients with more than one risk factor showed a higher prevalence of carotid lesions (84%) than those with only one risk factor (16%). In conclusion, the prevalence of carotid disease in asymptomatic patients, at risk for atherosclerosis, is high. The echo color Doppler system represents the best approach to study carotid atherosclerosis in vivo. When carotid lesions are present, a non invasive cardiological evaluation may be useful to reveal a silent coronary artery disease.

Improvement in cardiac function and clinical status has been described in subgroups of patients with dilated cardiomyopathy (DCM), but predictors of favourable outcome have not been unequivocally established. In 33 patients with DCM followed up for a mean of 23 months (range 3-68) a full non-invasive and invasive diagnostic work-up, including endomyocardial biopsy, was performed. At the end of the follow-up, 13 patients (39%; Group A) showed a significant improvement in their clinical status (or = 1 gain in NYHA functional class) and cardiac function (0.10 increase in echocardiographic ejection fraction), while 20 (61%; Group B) either stabilized or deteriorated (5 died and 4 underwent successful heart transplantation). Clinical, hemodynamic and morphometric data of the 2 groups were compared. Only lower systemic vascular resistance (Group A 2,836 +/- 637 versus Group B 3,637 +/- 1113; p = 0.025) and higher prevalence of alcohol intake80 g/day (Group A 85% versus Group B 40%; p = 0.03) were significantly associated with improvement. Discriminant analysis utilizing these 2 variables along with cardiac index, mitral regurgitation, pulmonary resistance and cardiothoracic ratio reached a discriminant power of 72% (p = 0.0014). The above results suggest that, in our series, relatively simple data provide the most accurate assessment of prognosis. Yet, prediction of favourable versus unfavourable outcome remains uncertain, since an incorrect prognosis will be made in 28% of cases. Morphometric analysis of endomyocardial bioptic specimens does not provide significant prognostic information. The identification of a high alcohol intake has a clinical relevance, since abstention from alcoholic beverages is significantly associated with a favourable outcome in our patients.

A fusiform aneurysm of the left main coronary artery without associated obstructive disease was detected in a 77-year-old patient with severe unstable angina treated with systemic thrombolysis. The authors emphasize the following features: (1) unusual location of the aneurysm, (2) absence of concomitant obstruction in this age group, and (3) clinical efficacy of thrombolysis and subsequent long-term oral anticoagulation.© 1993 Wlley-Liss, Inc

Objectifs Proposition d’un nouveau systeme de protection cerebrale base sur 5 points : 1) La bifurcation carotidienne est un site anatomi-que unique a cause du sinus carotidien : il represente un filtre naturel ou viennent se deposer les particules atheromateuses circulantes sur un espace limite +++, 2) L’occlusion temporaire de la carotide interne distale est la protection la plus efficace, 3) Avec les stents auto-expansibles le temps de post-dilatation (rupture de la plaque) est le seul presentant un vrai risque de complication embolique, 4) Les stents longs sont satisfaisants, 5) La tortuosite des vaisseaux est la consequence de la degenerescence vasculaire. Il n’y a aucun interet a la conserver. Materiels et methodes Le nouveau systeme de protection cerebrale associe une protection cerebrale par ballonnet et un ballon de postdilatation, introduits ensemble mais independants l’un de l’autre. Son but est de focaliser l’ensemble des gestes sur une zone tres reduite et d’obtenir une protection cerebrale efficace en la limitant a la postdilatation. Nombre de patients : 210. Symptomatiques 32,5 %. Resultats Presence de debris dans le sang aspire 16,3 %. Temps d’occlusion moyen : 3,9 minutes. Complications : 4 (1,9 %). Conclusion Les premiers resultats de ce systeme confirment sa simplicite d’utilisation et le bien fonde des choix techniques.

A case of coronary occlusion occurred seven days after successful percutaneous transluminal coronary angioplasty. The acute complication occurred shortly after a negative exercise stress test and was resolved with intracoronary urokinase.

The intravenous dipyridamole test is considered a safe procedure with a very low incidence of severe cardiac effects and is routinely used in the diagnosis and prognosis of coronary artery disease. We report the case of a 63-year-old female with negative exercise stress test who developed prolonged and extensive myocardial ischemia after the high-dose intravenous dipyridamole echocardiography test. Aminophylline and nitroglycerin were employed but were ineffective and the patient was successfully treated with systemic thrombolysis. At coronary angiography, 48 hours later, a 50% stenosis in the proximal LAD was documented. We stress that high-dose intravenous dipyridamole can induce a severe ischemic response whose occurrence is unpredictable according to the pre-test clinical features.